19 Reports
Inspection Report — May 6, 2026
Complaint Investigation
Date: May 6, 2026
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On-site complaint investigation of complaints 00166520 and 2988559 at a Nursing Care Institution, conducted 6 May 2026.
Complaint Details
The onsite complaint survey was conducted on May 6, 2026, and investigated complaint #00166520. The onsite complaint survey was conducted on May 6, 2026, and investigated complaint #2988559. There were no deficiencies noted.
Findings
No deficiencies were found during this complaint investigation.
Report Facts
Complaints investigated: 2
Inspection Report — Apr 21, 2026
Complaint Investigation
Date: Apr 21, 2026
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On-site complaint investigation of intakes 2979242 and 2986743 at a Nursing Care Institution, conducted 21 April 2026.
Complaint Details
The complaint survey was conducted 4/21/2026, with investigation of intakes: 2979242 and 2986743. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies or citations.
Inspection Report — Jan 9, 2026
Date: Jan 9, 2026
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On-site inspection of type 'Other' with Nursing Care Institution worksheet at Alta Mesa Health and Rehabilitation conducted 9 January 2026.
Findings
This inspection found no deficiencies or citations.
Inspection Report — Feb 21, 2025
Complaint Investigation
Date: Feb 21, 2025
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On-site complaint investigation at ALTA MESA HEALTH AND REHABILITATION conducted 21 February 2025. The investigation was initiated for an unspecified intake number.
Complaint Details
A complaint survey was conducted on February 21, 2025 for the investigation of intake # ______________. There were no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Jan 7, 2025
Complaint Investigation
Date: Jan 7, 2025
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On-site complaint investigation of intakes AZ00196556, AZ00196847, AZ00196682, and AZ00221228 at a Nursing Care Institution, conducted 7 January 2025.
Complaint Details
An onsite complaint survey was conducted on January 7, 2025 for the investigation of intake # AZ00196556, AZ00196847, AZ00196682, AZ00221228. There were no deficiencies cited. Federal comments note investigation of intake # AZ00196554, AZ00196847, AZ00196682, AZ00221227 with no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Inspection Report — Dec 18, 2024
Complaint Investigation
Date: Dec 18, 2024
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On-site complaint investigation of intake # AZ00220334 and intake # AZ00220332 at a Nursing Care Institution, conducted 18 December 2024.
Complaint Details
An onsite complaint survey was conducted on December 18, 2024 for the investigation of intake # AZ00220334. An onsite complaint survey was conducted on December 18, 2024 for the investigation of intake # AZ00220332.
Findings
This inspection resulted in no deficiencies cited.
Report Facts
Complaints investigated: 2
Inspection Report — Nov 26, 2024
Date: Nov 26, 2024
Visit Reason
Recertification survey for Medicare under the Life Safety Code 2012, Chapter 19, Existing Health Care Occupancies, conducted at Alta Mesa Health and Rehabilitation on 26 November 2024.
Findings
No deficiencies were found during this inspection. The facility met all applicable standards based on acceptance of a plan of correction.
Inspection Report — Nov 20, 2024
Annual Inspection
Date: Nov 20, 2024
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On-site complaint investigation and annual compliance survey conducted November 18 through 20, 2024, at Alta Mesa Health and Rehabilitation, addressing multiple complaint intake numbers including AZ00173016 and AZ00178993.
Complaint Details
The State compliance survey was conducted in conjunction with investigation of intake numbers AZ00173016, AZ00173455, AZ00174254, AZ00174293, AZ00174565, AZ00174853, AZ00175673, AZ00178641, AZ00178980 and AZ00178993. The federal recertification survey was conducted alongside investigation of intake numbers AZ00172664, AZ00173454, AZ00174253, AZ00174291, AZ00174564, AZ00174852, AZ00175672, AZ00178639, AZ00178980 and AZ00178991.
Findings
The inspection found two deficiencies: inaccurate and incomplete daily nursing staff postings regarding hours worked, and failure to administer oxygen as ordered to a resident. The facility was cited for staffing documentation errors and not providing oxygen therapy as prescribed.
Deficiencies (2)
R9-10-412 — The facility failed to ensure the Daily Staff Postings for nursing staff were accurate and complete for scheduled and actual hours worked, with discrepancies noted in multiple postings and staff interviews confirming errors.
R9-10-419 — The facility failed to administer oxygen as ordered to resident #510, who was observed not receiving oxygen despite an active physician order and documented medication administration records.
Report Facts
Deficiencies cited: 2
Complaints investigated: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #39 | Certified Nursing Assistant | Interviewed about staffing and workload on November 19, 2024 |
| Staff #31 | Staffing Coordinator | Interviewed regarding staffing and hours worked discrepancies on November 20, 2024 |
| Staff #83 | Administrator | Interviewed regarding staffing concerns and facility policies on November 20, 2024 |
| Staff #61 | Certified Nursing Assistant | Interviewed about oxygen administration for resident #510 on November 20, 2024 |
| Staff #113 | Licensed Practical Nurse | Interviewed about oxygen administration procedures on November 20, 2024 |
| Staff #76 | Assistant Director of Nursing | Interviewed about oxygen administration and clinical record review on November 20, 2024 |
Inspection Report — Nov 20, 2024
Complaint Investigation
Date: Nov 20, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding failure to administer oxygen as ordered to a resident and concerns about inaccurate nurse staffing postings and staffing shortages.
Complaint Details
The complaint investigation found that resident #510 was not administered oxygen as ordered despite physician orders and documentation. Interviews with staff confirmed the resident was not on oxygen. Additionally, staffing postings were inaccurate with discrepancies in hours worked, and residents reported concerns about short staffing and long call light wait times.
Findings
The facility failed to ensure that one sampled resident (#510) received oxygen as ordered, despite physician orders and documentation indicating oxygen administration. Additionally, the facility failed to maintain accurate daily nurse staffing postings, with discrepancies between scheduled and actual hours worked, and residents reported concerns about staffing shortages and long wait times for care.
Deficiencies (2)
Failure to provide safe and appropriate respiratory care by not administering oxygen as ordered to resident #510.
Failure to ensure accurate and complete daily nurse staffing postings, resulting in discrepancies between scheduled and actual hours worked.
Report Facts
Oxygen order flow rate: 2
Oxygen titrate flow rate: 5
CNA workload: 28
RN hours discrepancy: 4.58
RN hours per resident per day: 23
National average RN hours per resident per day: 28
Arizona average RN hours per resident per day: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) Staff #61 | Interviewed regarding oxygen administration process and confirmed resident was not on oxygen | |
| Licensed Practical Nurse (LPN) Staff #113 | Interviewed about oxygen administration process and risks of non-administration | |
| Assistant Director of Nursing (ADON) Staff #76 | Verified oxygen orders and charting, discussed risks of non-administration | |
| Certified Nursing Assistant (CNA) Staff #39 | Interviewed about staffing workload and weekend staffing | |
| Staffing Coordinator Staff #31 | Interviewed about staffing calculations, discrepancies, and census | |
| Administrator Staff #83 | Interviewed about staffing concerns, complaints, and CMS staffing rating |
Inspection Report — Sep 24, 2024
Complaint Investigation
Date: Sep 24, 2024
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On-site complaint investigation of complaints AZ00216022, AZ00214375 and AZ00216029 at a Nursing Care Institution, conducted 24 September 2024.
Complaint Details
The complaint survey was conducted on September 25, 2024 through September 25, 2024 of the following complaint #'s AZ00216022, AZ00214375 and AZ00216029. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 3
Inspection Report — Aug 12, 2024
Complaint Investigation
Date: Aug 12, 2024
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On-site complaint investigation of intake numbers AZ00213650, AZ00213570, AZ00214164 at a Nursing Care Institution, conducted 12 August 2024.
Complaint Details
The complaint survey was conducted on August 12, 2024, investigating intake numbers AZ00213650, AZ00213570, and AZ00214164. No deficiencies were cited.
Findings
This inspection resulted in no deficiencies or citations.
Report Facts
Complaints investigated: 3
Inspection Report — Jul 5, 2024
Complaint Investigation
Date: Jul 5, 2024
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On-site complaint investigation of complaint intake AZ00212558 at a Nursing Care Institution, conducted 3 July 2024.
Complaint Details
The investigation of Facility Reported Investigation AZ00212558 was conducted on July 03, 2024. The investigation of complaint intake #AZ00212558 was conducted on July 03, 2024. There were no deficiencies cited.
Findings
This inspection resulted in no citations or deficiency findings.
Inspection Report — Dec 29, 2023
Complaint Investigation
Date: Dec 29, 2023
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On-site complaint investigation of complaints AZ00204603, AZ00204628, and AZ00204602 at a Nursing Care Institution, conducted 28 December 2023.
Complaint Details
The complaint survey was conducted on 12/28/23 with the investigation of complaints AZ00204603, AZ00204628, and AZ00204602. The census was 57. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies or citations.
Report Facts
Complaints investigated: 3
Inspection Report — Oct 5, 2023
Complaint Investigation
Date: Oct 5, 2023
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On-site complaint investigation of complaint AZ00201052 at a Nursing Care Institution, conducted 4-5 October 2023.
Complaint Details
A complaint survey was conducted on October 4, 2023 through October 5, 2023 for the investigation of AZ00201052 and AZ00201051. There were no deficiencies sited.
Findings
This inspection found no deficiencies.
Inspection Report — Sep 25, 2023
Date: Sep 25, 2023
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On-site other type inspection of a Nursing Care Institution at ALTA MESA HEALTH AND REHABILITATION conducted 25 September 2023.
Findings
No deficiencies were found during this inspection; the facility met all applicable standards and requirements.
Inspection Report — Sep 15, 2023
Annual Inspection
Date: Sep 15, 2023
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On-site complaint investigation and annual compliance survey conducted September 11 through September 15, 2023 at Alta Mesa Health and Rehabilitation, including complaints AZ00200005, AZ00200020, AZ00199040, and AZ00199323.
Complaint Details
The state compliance survey was conducted September 11 through September 14, 2023 in conjunction with the investigation of complaints # AZ00200005, AZ00200020, AZ00199040, AZ00199323. The federal recertification survey was conducted in conjunction with complaints # AZ200019, AZ00200004, AZ00199633, AZ00199040, AZ00199320.
Findings
The inspection found eight deficiencies including failures in medication monitoring and notification, care planning for bathing, chemical storage safety, and food storage practices. Plans of correction were provided for all deficiencies.
Deficiencies (8)
R9-10-403 — The facility failed to ensure resident #215 received treatment and care according to professional standards, including failure to notify the physician or pharmacy of a critical vancomycin trough lab result of 49.6, resulting in no medication adjustment before the resident's death.
Care planning — The facility failed to implement a care plan for bathing for resident #17, who required extensive assistance, risking skin issues and poor hygiene.
§ 483.25 — The facility failed to ensure resident #215 received treatment and care in accordance with professional standards, including failure to notify providers of elevated vancomycin trough levels and failure to hold or adjust medication doses accordingly.
§483.25(d) — The facility failed to ensure chemicals were safely stored, with multiple hazardous chemicals stored on an open shelf in the kitchen and the kitchen door observed open, risking resident injury.
§483.60(i) — The facility failed to ensure food was properly stored, including uncovered or unsealed items in the walk-in refrigerator and freezer, risking loss of freshness and contamination.
R9-10-414 — The facility failed to develop and implement a care plan for bathing for resident #17 within seven days after assessment, risking skin issues and poor hygiene.
R9-10-423 — The facility failed to ensure food was stored, refrigerated, and reheated properly to meet dietary needs, including uncovered and unsealed food items.
R9-10-425 — The facility failed to maintain poisonous or toxic materials in labeled containers in a locked area separate from food and medications, with chemicals stored on an open shelf and the kitchen door open.
Report Facts
Deficiencies cited: 8
Complaints investigated: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #60 | Licensed Practical Nurse | Interviewed about vancomycin trough monitoring and notification procedures. |
| Staff #102 | Assistant Director of Nursing | Interviewed about vancomycin trough monitoring and notification procedures. |
| Staff #12 | Director of Nursing | Interviewed about vancomycin trough monitoring and notification procedures and care planning. |
| Staff #7 | MDS Coordinator | Interviewed about care plan requirements for bathing. |
| Staff #11 | Dietary Supervisor | Interviewed about chemical and food storage practices. |
| Staff #188 | Administrator | Interviewed about chemical and food storage policies and supervision. |
Inspection Report — Sep 15, 2023
Routine
Date: Sep 15, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, medication management, safety, and food storage at Alta Mesa Health and Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to implement a care plan for bathing for one resident, improper monitoring and notification of critical vancomycin lab levels resulting in a resident's death, unsafe chemical storage in the kitchen, and improper food storage practices that could affect food quality.
Deficiencies (4)
Failure to develop and implement a complete care plan for bathing for one resident (#17).
Failure to provide appropriate treatment and care according to orders and professional standards for resident (#215), including failure to notify provider or pharmacy of critical vancomycin lab results.
Failure to ensure chemicals were safely stored in the kitchen, with chemicals stored on an open shelf and kitchen door left open.
Failure to properly store food in the kitchen, including uncovered or unsealed food items and food with holes in coverings.
Report Facts
Vancomycin serum trough level: 49.6
Vancomycin administration dates: 7
Discard date: 2023
Spray bottle volume: 3
Spray bottle volume: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #7 | MDS Coordinator | Interviewed regarding care plan for bathing for resident #17 |
| Staff #12 | Director of Nursing (DON) | Interviewed regarding bathing care plan and vancomycin lab notification for resident #215 |
| Staff #60 | Licensed Practical Nurse (LPN) | Interviewed regarding vancomycin trough monitoring and notification procedures |
| Staff #102 | Assistant Director of Nursing (ADON) | Interviewed regarding vancomycin trough monitoring and notification procedures |
| Staff #11 | Dietary Supervisor | Interviewed regarding chemical and food storage practices |
| Staff #84 | Nursing Staff | Written up for failure to confirm lab values prior to medication administration |
| Administrator #188 | Administrator | Interviewed regarding chemical and food storage policies and supervision |
Inspection Report — Aug 2, 2023
Complaint Investigation
Date: Aug 2, 2023
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On-site complaint investigation of complaints AZ00198033 and AZ00198032 at a Nursing Care Institution, conducted 2 August 2023.
Complaint Details
The Complaint AZ00198033 was investigated on 8/2/23. The Complaint AZ00198032 was investigated on 8/2/23. No deficiencies were cited.
Findings
No deficiencies were found during this complaint investigation.
Report Facts
Complaints investigated: 2
Inspection Report — Aug 4, 2022
Complaint Investigation
Date: Aug 4, 2022
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to properly screen and hire staff with prior disciplinary actions, failure to complete required PASARR screenings for certain residents, and medication administration errors.
Complaint Details
The complaint investigation substantiated that the facility failed to properly screen and hire staff with prior disciplinary actions, failed to complete required PASARR screenings, and had medication administration errors exceeding acceptable rates.
Findings
The facility failed to ensure a Certified Nursing Assistant with a prior abuse/neglect disciplinary action was not hired, failed to complete or update PASARR screenings for residents staying longer than 30 days, and failed to administer medications according to physician orders, resulting in an 8.57% medication error rate.
Deficiencies (5)
Failure to ensure a Certified Nursing Assistant was not hired with a finding of resident abuse or neglect from the State professional licensing board.
Failure to develop and implement policies and procedures to prevent abuse, neglect, and theft, specifically failing to implement hiring policy for a CNA with prior disciplinary action.
Failure to ensure PASARR screening was completed for one resident and updated for two residents who remained in the facility longer than 30 days.
Failure to ensure medication administration met professional standards of quality for two residents, including administering medications not as prescribed.
Failure to ensure medication error rates were not 5 percent or greater, with an error rate of 8.57% due to incorrect medication administration for one resident.
Report Facts
Medication error rate: 8.57
Medication error rate threshold: 5
Hire date: Jun 20, 2022
Certification expiration date: Jul 31, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) staff #3 | Named in deficiency for being hired with prior disciplinary action for abuse/neglect | |
| Director of Nursing (DON) staff #48 | Interviewed regarding hiring process and medication administration findings | |
| Human Resources Director staff #20 | Interviewed regarding certification verification and hiring process | |
| Executive Director (ED) staff #66 | Interviewed regarding hiring process and notification of disciplinary actions | |
| Licensed Practical Nurse (LPN) staff #106 | Observed administering medication and interviewed about medication administration | |
| Licensed Practical Nurse (LPN) staff #110 | Observed administering medication and interviewed about medication errors | |
| Activities/Social Services Supervision staff #54 | Interviewed regarding PASARR screening process |
4 CMS Surveys
CMS Survey — Nov 20, 2024
Nov 20, 2024
CMS Survey — Aug 4, 2022
Aug 4, 2022
CMS Survey — Sep 15, 2023
Sep 15, 2023
CMS Survey — Nov 20, 2024
Nov 20, 2024
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